“Don’t tell me TB is under control!” Understanding TB First Africa-Region TB/HIV Advocacy Workshop 19-21 June 2006.

“Don’t tell me TB is under control!”

Understanding TB

First Africa-Region TB/HIV Advocacy Workshop

19-21 June 2006

Overview

• Brief history of TB• What is TB?• Where do we get TB from?• How to prevent TB?• TB disease• Diagnosing TB• Treatment of TB• WHO TB Control Strategy

A brief history of TB

• Nwabisa Njaba– Living openly with TB, coughing blood and

losing weight

A brief history of TB

• Lihle Dlamini– “High fever for one month, not coughing,

losing lots of weight”• Unusual signs and symptoms for TB • Not presenting early• Did not see loss of weight as reason for

seeking assistance

A brief history of TB

• Shane King– Risk of TB for PWAs “Dr Sweetness” – Multi-drug resistant TB– Adherence (? Take 6 months ‘cos its better

than 18 months)

A brief history of TB

• TB is common• TB in people living with HIV is common• TB in people living with HIV is difficult to

diagnose• TB in people living with HIV is difficult to treat• TB is a common cause of HIV-related deaths• TB can be prevented, treated and cured!

A brief history of TB

www.who.int/afro/TB

Issues for Advocacy

• “Tuberculosis is an emergency in the African region!”– How does this recognition translate into

country specific action?– What is the role of civil society in

contributing to this state of emergency?– What is popular, community knowledge

and actions on TB?

What is TB?

• Bacterium

• Mycobacteria family (“genus”)

• Mycobacteria– Tuberculosis (“species”)– Bovis– Microti

• “M. tuberculosis”

Where do we get TB from?

• Person infected and sick with TB• Lives in air as part of droplets• Inhaled into lungs

1. Killed by immune system2. Multiply and cause disease3. Become inactive inside immune cells, no

disease, immune cells move all over body4. Become “reactivated” and cause illness

Where do we get TB from?

1. Killed by immune system

2. Multiply and cause disease– Primary disease

3. Become inactive inside immune cells, no disease, immune cells move all over body

– Latent infection

4. Become “reactivated” and cause illness– Reactivation disease

Living with HIV and TB Infection

• TB infection makes HIV worse

• HIV infection makes TB worse

Immune cellMacrophage

Tuberculosis bacteria

I have TB!TNF-α

Immune cellCD 4 Cell

Cells talk!Antigen-presentation

CD 4 cellsactivated!

Mobilise against the TB infection!

IFN-γ

Mobilise against the TB infection!

IFN-γ

HIV

Immune cellCD 4 Cell

Cells talk!Antigen-presentation

KJIl :) coffee TB, Ghana 2 Czech 0 I wonder when

this TB guy will be done?!

?

?

?

Living with HIV and TB Infection

• TB infection makes HIV worse– More CD 4 cells infected with HIV– Faster “disease progression”

• HIV infection makes TB worse– More reactivation TB– More disseminated TB

How to prevent TB disease?

1. Broader strategies

2. TB vaccination

3. TB prevention – “INH”

4. TB prevention – “HAART”

How to prevent TB disease?

• Broader strategies

Access and maintenance of– Housing security– Food security – Health security (“health systems”)

How to prevent TB disease?

• TB vaccination• BCG vaccine

– At birth, also to “HIV exposed” infants – Not for “newborns with AIDS”

• Benefit:– Good protection against “extrapulmonary

TB” (e.g. TB meningitis)– Uncertain protection for pulmonary TB

Handbook of HIV Medicine

How to prevent TB disease?

• “Isoniazid prophylaxis” OR “INH prophylaxis”

• Antituberculous medication• Benefit:

– 60% reduced chance of developing TB disease

– Survival improved

www.doh.gov.za

How to prevent TB disease?

At risk persons?– Household “TB contacts” – People living with HIV– Healthcare workers working in clinics with

many TB service users– Mineworkers– Prisoners

How to prevent TB disease?

• “INH prophylaxis”

How?– Identify at risk persons– Positive “tuberculin skin test”– Exclude TB disease (“TB culture”)– Isoniazid daily for 6 months

How to prevent TB disease?

• “INH prophylaxis”

Who should not consider TB prophylaxis?– Persons with signs and symptoms suggestive of

TB– Current liver disease– Active alcohol dependence– Previously on TB treatment– Currently on HAART– Living with HIV and “tuberculin skin test” negative

Issues for Advocacy

• Broader strategies on housing, food, health security

• Improved recognition of TB disease (see TB diagnostics)

• How to include TB prevention strategies into existing TB programs?

TB Disease

• Common signs and symptoms - Adults

• Pulmonary – Coughing– Weight loss – Night sweats– Coughing blood

TB Disease

• Common signs and symptoms - Adults

• “Extrapulmonary”– Anywhere outside the lungs!– TB lymph nodes (“lymphadenitis”)– TB meningitis– TB bones (e.g. TB spine)

TB Disease

• Common signs and symptoms – Infants and children

• Pulmonary – Failure to thrive– Coughing more than 2 weeks– Night sweats– Prolonged fever– Adult “TB contact”

TB Disease

• Common signs and symptoms – Infants and children

• “Extrapulmonary”– Anywhere outside the lungs!– TB lymph nodes (“lymphadenitis”)– TB meningitis– TB bones (e.g. TB spine)

TB Disease

• In people living with HIV, TB should be considered if only:– Weight loss OR– Prolonged fever OR– No response to treatment regimens for

other diagnoses

Issues for advocacy

• Popular knowledge about TB signs and symptoms for “self-diagnosis”

• Early and effective diagnosis and treatment

• INH prophylaxis for household contacts of persons with TB disease

• Healthcare workers raised suspicion of TB

Diagnosing TB

• Adults with suspected pulmonary TB– Signs and symptoms– At least two sputum for “TB microscopy”

• “Ziehl-Niehlsen” stain• Reported as “Acid-fast bacilli” or “AFBs”• Reported as “Smear-positive”

Diagnosing TB

• Adults with suspected pulmonary TB– “Smear-negative TB”

• Too few TB bacteria too identify under microscope

– Next test, “TB culture”• Result takes up to 6 weeks from start of test• Reported as “culture positive TB” or

“smear-negative and culture positive TB”

Diagnosing TB

• Can we treat smear-negative without a TB culture?– WHO recommends

• Three sputum tests reported as negative for “AFBs”

• No response to “broad spectrum antibiotics”• Chest X-ray that is consistent with pulmonary

TB • Experienced healthcare worker

Diagnosing TB

• Adults with suspected extrapulmonary TB– TB lymphadenitis “biopsy” TB culture– TB meningitis “lumbar puncture” TB

microscopy and other tests

Diagnosing TB

• Infants and children– Questions

• BCG vaccination?

– Tests• Tuberculin Skin Test• Chest X-ray• Microscopy and culture

Issues for advocacy

• Improved use of existing tools especially TB culture

• New diagnostic tools to be developed

• New diagnostic tools suited to infants and children

Treating TB

• First TB diagnosis - “TB regimen 1”– 6 months– First 2 months

• Four drug regimen, 3 or 5 days per week• Tb sputum for microscopy (“smear-conversion”)

– Last 4 months• Four drug regimen, 3 or 5 days per weeks

Treating TB

• Extrapulmonary TB– Longer course (e.g. TB spine 12 months)– steroids, cotrimoxazole, vitamin B and

needs to start HAART

• Second pulmonary TB diagnosis – 9 months

• Side effects of TB treatment• Multi-Drug Resistant TB (“MDR TB”)

Treating TB

• When to start HAART?– Adults– Infants and children

• “IRIS”

Treating TB

• Adherence to TB medication

• DOTS (Directly Observed Therapy Short Course)

• “Treatment Supporter”

Treating TB

• WHO DOTS for TB and HIV– Commitment from government– Finding persons with TB (“case detection”)

including VCT for HIV– Standard TB and HAART regimens– Regular drug supplies– Monitoring system (“treatment completion”)

Issues for advocacy

• Improved application of DOTS

• Improved TB treatment completion rates

• Improved drugs!

• Availability and cost of drugs for MDR-TB

• “DOTS does not work if not owned by communities!”